What is the treatment for acute mastoiditis in children?

Treatment of Acute Mastoiditis in Children

The primary treatment for acute mastoiditis in children consists of hospitalization with intravenous antibiotics, with or without myringotomy, and surgical intervention reserved for complicated cases or those failing to respond to initial medical management. 1

Diagnosis and Initial Assessment

• Acute mastoiditis is the most common complication of acute otitis media (AOM)
• Clinical presentation typically includes:
  • Post-auricular erythema, edema, and tenderness
  • Protrusion of the auricle
  • Fever
  • Signs of AOM (bulging tympanic membrane)

Treatment Algorithm

Step 1: Initial Medical Management

• Hospitalization with intravenous broad-spectrum antibiotics

  • First-line: Intravenous cephalosporins (due to prevalence of Streptococcus pneumoniae) 2
  • Consider combination therapy when multibacterial flora is suspected
  • Common pathogens include S. pneumoniae, S. pyogenes, H. influenzae, and S. aureus 2

• Myringotomy should be performed in all cases at admission to:

  • Relieve pressure
  • Obtain cultures
  • Facilitate drainage 3

Step 2: Monitoring Response (48-72 hours)

• Monitor for clinical improvement:
  • Decreasing fever
  • Reduction in post-auricular swelling
  • Improvement in general condition

Step 3: Management Based on Response

• If improving: Continue IV antibiotics until significant clinical improvement, then transition to oral antibiotics to complete 10-14 day course
• If not improving within 48-72 hours or if clinical deterioration occurs:
  • Obtain CT scan to assess for complications
  • Proceed to surgical intervention 1

Step 4: Surgical Management (when indicated)

• Indications for immediate surgical intervention:

  • Subperiosteal abscess: Drainage or simple mastoidectomy
  • Intracranial complications: Simple mastoidectomy with neurosurgical consultation
  • Failure to respond to medical therapy within 3-5 days 3

• Surgical options:

  • Needle aspiration of subperiosteal abscess
  • Incision and drainage of abscess
  • Simple mastoidectomy
  • Cortical mastoidectomy

Evidence for Treatment Approach

A review of 577 cases of acute mastoiditis from Sweden showed that 10% of patients were successfully treated with antibiotics alone, 68% with antibiotics and myringotomy, and 22% required antibiotics and mastoidectomy 1. This demonstrates that while many cases can be managed without major surgery, a significant portion will require surgical intervention.

In another study, 87% of patients with uncomplicated mastoiditis recovered following intravenous antibiotics and myringotomy, with only 11.4% requiring mastoidectomy or abscess drainage 4.

Management of Complications

Complications of acute mastoiditis can be categorized as:

1. Extracranial: Subperiosteal abscess, Bezold's abscess
2. Intratemporal: Facial nerve palsy, labyrinthitis
3. Intracranial: Meningitis, brain abscess, sinus thrombosis

All complicated cases require aggressive management with:

• Intravenous antibiotics
• Surgical intervention (typically mastoidectomy)
• Additional specific treatments based on complication type (e.g., anticoagulants for sinus thrombosis) 2

Important Considerations

• Despite prior antibiotic treatment for AOM, children can still develop acute mastoiditis 1
• Tympanocentesis for middle ear culture is valuable in cases of antibiotic treatment failures 5
• Surgical therapy is becoming more frequently necessary due to increasing antibiotic resistance 5
• Early intervention with appropriate antibiotics is crucial to prevent potentially serious complications 6

Follow-up

• Close monitoring after discharge
• Complete full course of antibiotics
• Audiologic evaluation after resolution to assess for hearing loss

By following this algorithmic approach to the management of acute mastoiditis in children, clinicians can effectively treat this serious condition while minimizing complications and optimizing outcomes.